Protein intake in children and growth and risk of overweight or obesity: A systematic review and meta-analysis

Keywords: dietary protein, early life nutrition, infant feeding, growth, BMI, overweight, obesity, metabolic programming, dietary guidelines, systematic reviews


Objectives: The aim of this study was to examine the evidence for an association between the dietary protein intake in children and the growth and risk of overweight or obesity up to 18 years of age in settings relevant for the Nordic countries.

Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus up to February 26, 2021 for randomized controlled trials (RCTs) or prospective cohort studies assessing for protein intake from foods (total and from different sources) in children. The outcomes include weight, height/length, adiposity indices, and/or risk of overweight and/or obesity. The risk of bias was evaluated with instruments for each respective design (Cochrane’s Risk of Bias 2.0 and RoB-NObS). A meta-analysis of five cohort studies was performed. The evidence was classified according to the criteria of the World Cancer Research Fund.

Results: The literature search resulted in 9,132 abstracts, of which 55 papers were identified as potentially relevant. In total, 21 studies from 27 publications were included, of which five were RCTs and 16 were cohort studies. The RCTs found generally null effects of high-protein intake in infants on weight gain, nor that lower protein diets negatively affected growth. All included RCTs had some concern regarding the risk of bias and were limited by small sample sizes. Total protein intake and BMI were assessed in 12 cohorts, of which 11 found positive associations. The meta-analysis revealed a pooled effect estimate of 0.06 (95% CI 0.03, 0.1) kg/m2 BMI per one E% increment in total protein (I2 = 15.5). Therefore, the evidence for a positive relationship between total protein intake and BMI was considered probable. Furthermore, there was probable evidence for an association between higher intake of animal protein and increased BMI. There was limited, suggestive evidence for an effect of total protein intake and higher risk of overweight and/or obesity, while no conclusions could be made on the associations between animal vs. plant protein intake and risk of overweight and/or obesity.

Discussion: In healthy, well-nourished children of Western populations, there is probably a causal relationship between a high-protein intake in early childhood (≤ 18 months) – particularly protein of animal origin – and higher BMI later in childhood, with consistent findings across cohort studies. A lack of RCTs precluded a stronger grading of the evidence.


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  1. NCD Risk Factor Collaboration. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2,416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet 2017; 390(10113): 2627–42. doi: 10.1016/S0140-6736(17)32129-3

  2. Garrido-Miguel M, Cavero-Redondo I, Alvarez-Bueno C, Rodriguez-Artalejo F, Moreno LA, Ruiz JR, et al. Prevalence and trends of overweight and obesity in European children from 1999 to 2016: a systematic review and meta-analysis. JAMA Pediatr 2019; 173(10): e192430. doi: 10.1001/jamapediatrics.2019.2430

  3. Nordic Council of Ministers. Nordic Nutrition Recommendations 2012: integrating nutrition and physical activity. Copenhagen: Nordic Council of Minsters; 2014.

  4. Rolland-Cachera MF, Deheeger M, Akrout M, Bellisle F. Influence of macronutrients on adiposity development: a follow up study of nutrition and growth from 10 months to 8 years of age. Int J Obes Rel Metab Disord 1995; 19(8): 573–8.

  5. Hornell A, Lagstrom H, Lande B, Thorsdottir I. Protein intake from 0 to 18 years of age and its relation to health: a systematic literature review for the 5th Nordic Nutrition Recommendations. Food Nutr Res 2013; 57: 21083. doi: 10.3402/fnr.v57i0.21083

  6. Pearce J, Langley-Evans SC. The types of food introduced during complementary feeding and risk of childhood obesity: a systematic review. Int J Obes (Lond) 2013; 37(4): 477–85. doi: 10.1038/ijo.2013.8

  7. Ferre N, Luque V, Closa-Monasterolo R, Zaragoza-Jordana M, Gispert-Llaurado M, Grote V, et al. Association of protein intake during the second year of life with weight gain-related outcomes in childhood: a systematic review. Nutrients 2021; 13(2): 583. doi: 10.3390/nu13020583

  8. Stokes A, Campbell KJ, Yu HJ, Szymlek-Gay EA, Abbott G, He QQ, et al. Protein intake from birth to 2 years and obesity outcomes in later childhood and adolescence: a systematic review of prospective cohort studies. Adv Nutr 2021; 12(5): 1863–1876. doi: 10.1093/advances/nmab034

  9. Nilsson M, Stenberg M, Frid AH, Holst JJ, Bjorck IM. Glycemia and insulinemia in healthy subjects after lactose-equivalent meals of milk and other food proteins: the role of plasma amino acids and incretins. Am J Clin Nutr 2004; 80(5): 1246–53. doi: 10.1093/ajcn/80.5.1246

  10. Christensen JJ, Arnesen EK, Andersen R, Eneroth H, Erkkola M, Høyer A, et al. The Nordic Nutrition Recommendations 2022 – principles and methodologies. Food Nutr Res 2020; 64: 4402. doi: 10.29219/fnr.v64.4402

  11. Høyer A, Christensen JJ, Arnesen EK, Andersen R, Eneroth H, Erkkola M, et al. The Nordic Nutrition Recommendations 2022 – prioritisation of topics for de novo systematic reviews. Food Nutr Res. 2021; 65: 7828. doi: 10.29219/fnr.v65.7828

  12. Arnesen EK, Christensen JJ, Andersen R, Eneroth H, Erkkola M, Høyer A, et al. The Nordic Nutrition Recommendations 2022 – handbook for systematic reviews. Food Nutr Res 2020; 64: 4404 doi: 10.29219/fnr.v64.4404

  13. Arnesen EK, Christensen JJ, Andersen R, Eneroth H, Erkkola M, Høyer A, et al. The Nordic Nutrition Recommendations 2022 – structure and rationale of systematic reviews. Food Nutr Res 2020; 64: 4403. doi: 10.29219/fnr.v64.4403

  14. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. doi: 10.1136/bmj.n71

  15. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 2021; 372: n160. doi: 10.1136/bmj.n160

  16. Sterne JA, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898. doi: 10.1136/bmj.l4898

  17. Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919. doi: 10.1136/bmj.i4919

  18. Viswanathan M, Patnode CD, Berkman ND, Bass EB, Chang S, Hartling L, et al. Recommendations for assessing the risk of bias in systematic reviews of health-care interventions. J Clin Epidemiol 2018; 97: 26–34. doi: 10.1016/j.jclinepi.2017.12.004

  19. Nutrition Evidence Systematic Review. Risk of Bias for Nutrition Observational Studies (RoB-NObs) tool 2019. Available from: [cited 06 February 2020].

  20. AHRQ. Methods guide for effectiveness and comparative effectiveness reviews. Rockville, MD: Agency for Healthcare Research and Quality; 2014.

  21. Morton SC, Murad MH, O’Connor E, Lee CS, Booth M, Vandermeer BW, et al. Quantitative synthesis – and update. 2018. In: Methods guide for effectiveness and comparative effectiveness reviews. Agency for Healthcare Research and Quality. Available from: [cited 3 September 2021].

  22. Deeks JJ, Higgins JPT, Altman DG. Analysing data and undertaking meta-analyses. In: Higgins JPT, Altman DG, editors. Cochrane handbook for systematic reviews of interventions, version 5.1.0. London: The Cochrane Collaboration, 2011; pp. 1–44.

  23. Sterne JAC, Egger M, Moher D. Addresing reporting biases. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration; 2011. Available from: [cited 1 February 2021].

  24. Svahn JC, Axelsson IE, Raiha NC. Macronutrient and energy intakes in young children fed milk products containing different quantities and qualities of fat and protein. J Pediatr Gastroenterol Nutr 1999; 29(3): 273–81. doi: 10.1097/00005176-199909000-00007

  25. Krebs NF, Westcott JE, Butler N, Robinson C, Bell M, Hambidge KM. Meat as a first complementary food for breastfed infants: feasibility and impact on zinc intake and status. J Pediatr Gastroenterol Nutr 2006; 42(2): 207–14. doi: 10.1097/01.mpg.0000189346.25172.fd

  26. Larnkjaer A, Hoppe C, Molgaard C, Michaelsen KF. The effects of whole milk and infant formula on growth and IGF-I in late infancy. Eur J Clin Nutr 2009; 63(8): 956–63. doi: 10.1038/ejcn.2008.80

  27. Tang M, Krebs NF. High protein intake from meat as complementary food increases growth but not adiposity in breastfed infants: a randomized trial. Am J Clin Nutr 2014; 100(5): 1322–8. doi: 10.3945/ajcn.114.088807

  28. Tang M, Hendricks AE, Krebs NF. A meat- or dairy-based complementary diet leads to distinct growth patterns in formula-fed infants: a randomized controlled trial. Am J Clin Nutr 2018; 107(5): 734–42. doi: 10.1093/ajcn/nqy038

  29. Tang M, Andersen V, Hendricks AE, Krebs NF. Different growth patterns persist at 24 months of age in formula-fed infants randomized to consume a meat- or dairy-based complementary diet from 5 to 12 months of age. J Pediatri 2019; 206: 78–82. doi: 10.1016/j.jpeds.2018.10.020

  30. Scaglioni S, Agostoni C, Notaris RD, Radaelli G, Radice N, Valenti M, et al. Early macronutrient intake and overweight at five years of age. Int J Obes Relat Metab Disord 2000; 24(6): 777–81. doi: 10.1038/sj.ijo.0801225

  31. Gunnarsdottir I, Thorsdottir I. Relationship between growth and feeding in infancy and body mass index at the age of 6 years. Int J Obes Relat Metab Disord 2003; 27(12): 1523–7. doi: 10.1038/sj.ijo.0802438

  32. Hoppe C, Molgaard C, Thomsen BL, Juul A, Michaelsen KF. Protein intake at 9 mo of age is associated with body size but not with body fat in 10-y-old Danish children. Am J Clin Nutr 2004; 79(3): 494–501. doi: 10.1093/ajcn/79.3.494

  33. Skinner JD, Bounds W, Carruth BR, Morris M, Ziegler P. Predictors of children’s body mass index: a longitudinal study of diet and growth in children aged 2–8 y. Int J Obes Relat Metab Disord 2004; 28(4): 476–82. doi: 10.1038/sj.ijo.0802405

  34. Gunther AL, Buyken AE, Kroke A. Protein intake during the period of complementary feeding and early childhood and the association with body mass index and percentage body fat at 7 y of age. Am J Clin Nutr 2007; 85(6): 1626–33. doi: 10.1093/ajcn/85.6.1626

  35. Gunther AL, Remer T, Kroke A, Buyken AE. Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Am J Clin Nutr 2007; 86(6): 1765–72. doi: 10.1093/ajcn/86.5.1765

  36. Ohlund I, Hernell O, Hornell A, Stenlund H, Lind T. BMI at 4 years of age is associated with previous and current protein intake and with paternal BMI. Eur J Clin Nutr 2010; 64(2): 138–45. doi: 10.1038/ejcn.2009.132

  37. Garden FL, Marks GB, Almqvist C, Simpson JM, Webb KL. Infant and early childhood dietary predictors of overweight at age 8 years in the CAPS population. Eur J Clin Nutr 2011; 65(4): 454–62. doi: 10.1038/ejcn.2011.7

  38. Thorisdottir B, Gunnarsdottir I, Palsson GI, Halldorsson TI, Thorsdottir I. Animal protein intake at 12 months is associated with growth factors at the age of six. Acta Paediatr 2014; 103(5): 512–17. doi: 10.1111/apa.12576

  39. Braun KV, Erler NS, Kiefte-de Jong JC, Jaddoe VW, van den Hooven EH, Franco OH, et al. Dietary intake of protein in early childhood is associated with growth trajectories between 1 and 9 years of age. J Nutr 2016; 146(11): 2361–7. doi: 10.3945/jn.116.237164

  40. Voortman T, Braun KV, Kiefte-de Jong JC, Jaddoe VW, Franco OH, van den Hooven EH. Protein intake in early childhood and body composition at the age of 6 years: the generation R study. Int J Obes 2016; 40(6): 1018–25. doi: 10.3945/jn.116.237164

  41. Voortman T, van den Hooven EH, Tielemans MJ, Hofman A, Kiefte-de Jong JC, Jaddoe VW, et al. Protein intake in early childhood and cardiometabolic health at school age: the generation R study. Eur J Nutr 2016; 55(6): 2117–27. doi: 10.1007/s00394-015-1026-7

  42. Pimpin L, Jebb S, Johnson L, Wardle J, Ambrosini GL. Dietary protein intake is associated with body mass index and weight up to 5 y of age in a prospective cohort of twins. Am J Clin Nutr 2016; 103(2): 389–97. doi: 10.3945/ajcn.115.118612

  43. Beyerlein A, Uusitalo UM, Virtanen SM, Vehik K, Yang J, Winkler C, et al. Intake of energy and protein is associated with overweight risk at age 5.5 years: results from the prospective TEDDY study. Obesity 2017; 25(8): 1435–41. doi: 10.1002/oby.21897

  44. Durao C, Oliveira A, Santos AC, Severo M, Guerra A, Barros H, et al. Protein intake and dietary glycemic load of 4-year-olds and association with adiposity and serum insulin at 7 years of age: sex-nutrient and nutrient-nutrient interactions. Int J Obes 2017; 41(4): 533–41. doi: 10.1038/ijo.2016.240

  45. Pimpin L, Jebb SA, Johnson L, Llewellyn C, Ambrosini GL. Sources and pattern of protein intake and risk of overweight or obesity in young UK twins. Br J Nutr 2018; 120(7): 820–9. doi: 10.1017/S0007114518002052

  46. Morgen CS, Angquist L, Baker JL, Andersen AN, Sorensen TIA, Michaelsen KF. Breastfeeding and complementary feeding in relation to body mass index and overweight at ages 7 and 11 y: a path analysis within the Danish National Birth Cohort. Am J Clin Nutr 2018; 107(3): 313–22. doi: 10.1093/ajcn/nqx058

  47. Smith-Brown P, Morrison M, Krause L, Newby R, Davies PS. Growth and protein-rich food intake in infancy is associated with fat-free mass index at 2–3 years of age. J Paediatr Child Health 2018; 54(7): 770–5. doi: 10.1111/jpc.13863

  48. Jen V, Braun KVE, Karagounis LG, Nguyen AN, Jaddoe VWV, Schoufour JD, et al. Longitudinal association of dietary protein intake in infancy and adiposity throughout childhood. Clin Nutr 2019; 38(3): 1296–302. doi: 10.1016/j.clnu.2018.05.013

  49. Switkowski KM, Jacques PF, Must A, Fleisch A, Oken E. Associations of protein intake in early childhood with body composition, height, and insulin-like growth factor I in mid-childhood and early adolescence. Am J Clin Nutr 2019; 109(4): 1154–63. doi: 10.1093/ajcn/nqy354

  50. Gunther AL, Buyken AE, Kroke A. The influence of habitual protein intake in early childhood on BMI and age at adiposity rebound: results from the DONALD study. Int J Obes 2006; 30(7): 1072–9. doi: 10.1038/sj.ijo.0803288

  51. Rolland-Cachera MF, Deheeger M, Maillot M, Bellisle F. Early adiposity rebound: causes and consequences for obesity in children and adults. Int J Obes (Lond) 2006; 30 Suppl 4: S11–17. doi: 10.1038/sj.ijo.0803514

  52. Fleddermann M, Demmelmair H, Grote V, Nikolic T, Trisic B, Koletzko B. Infant formula composition affects energetic efficiency for growth: the BeMIM study, a randomized controlled trial. Clin Nutr 2014; 33(4): 588–95. doi: 10.1016/j.clnu.2013.12.007

  53. Koletzko B, von Kries R, Closa R, Escribano J, Scaglioni S, Giovannini M, et al. Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial. Am J Clin Nutr 2009; 89(6): 1836–45. doi: 10.3945/ajcn.2008.27091

  54. Wall CR, Hill RJ, Lovell AL, Matsuyama M, Milne T, Grant CC, et al. A multicenter, double-blind, randomized, placebo-controlled trial to evaluate the effect of consuming growing up milk ‘lite’ on body composition in children aged 12–23 mo. Am J Clin Nutr 2019; 109(3): 576–85. doi: 10.1093/ajcn/nqy302

  55. Patro-Golab B, Zalewski BM, Kouwenhoven SM, Karas J, Koletzko B, Bernard van Goudoever J, et al. Protein concentration in milk formula, growth, and later risk of obesity: a systematic review. J Nutr 2016; 146(3): 551–64. doi: 10.3945/jn.115.223651

  56. Abrams SA, Hawthorne KM, Pammi M. A systematic review of controlled trials of lower-protein or energy-containing infant formulas for use by healthy full-term infants. Adv Nutr 2015; 6(2): 178–88. doi: 10.3945/an.114.006379

  57. English LK, Obbagy JE, Wong YP, Butte NF, Dewey KG, Fox MK, et al. Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review. Am J Clin Nutr 2019; 109(Suppl_7): 956S–77S. doi: 10.1093/ajcn/nqy281

  58. Luque V, Closa-Monasterolo R, Escribano J, Ferre N. Early programming by protein intake: the effect of protein on adiposity development and the growth and functionality of vital organs. Nutr Metab Insights 2015; 8(Suppl 1): 49–56. doi: 10.4137/NMI.S29525

  59. Lu J, Gu Y, Liu H, Wang L, Li W, Li W, et al. Daily branched-chain amino acid intake and risks of obesity and insulin resistance in children: a cross-sectional study. Obesity (Silver Spring) 2020; 28(7): 1310–16. doi: 10.1002/oby.22834

  60. Dorosty AR, Emmett PM, Cowin S, Reilly JJ. Factors associated with early adiposity rebound. ALSPAC study team. Pediatrics 2000; 105(5): 1115–18. doi: 10.1542/peds.105.5.1115

  61. NCD Risk Factor Collaboration. Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight. Elife 2021; 10: e60060. doi: 10.7554/eLife.60060

  62. Druet C, Stettler N, Sharp S, Simmons RK, Cooper C, Smith GD, et al. Prediction of childhood obesity by infancy weight gaIn: an individual-level meta-analysis. Paediatr Perinat Epidemiol 2012; 26(1): 19–26. doi: 10.1111/j.1365-3016.2011.01213.x

  63. Zheng M, Lamb KE, Grimes C, Laws R, Bolton K, Ong KK, et al. Rapid weight gain during infancy and subsequent adiposity: a systematic review and meta-analysis of evidence. Obes Rev 2018; 19(3): 321–32. doi: 10.1111/obr.12632

  64. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev 2016; 17(2): 95–107. doi: 10.1111/obr.12334

  65. Bjerregaard LG, Adelborg K, Baker JL. Change in body mass index from childhood onwards and risk of adult cardiovascular disease. Trends Cardiovasc Med 2020; 30(1): 39–45. doi: 10.1016/j.tcm.2019.01.011

  66. Meyer JF, Larsen SB, Blond K, Damsgaard CT, Bjerregaard LG, Baker JL. Associations between body mass index and height during childhood and adolescence and the risk of coronary heart disease in adulthood: a systematic review and meta-analysis. Obes Rev 2021; 22(9): e13276. doi: 10.1111/obr.13276

  67. Park MH, Falconer C, Viner RM, Kinra S. The impact of childhood obesity on morbidity and mortality in adulthood: a systematic review. Obes Rev 2012; 13(11): 985–1000. doi: 10.1111/j.1467-789X.2012.01015.x

  68. Flegal KM, Ogden CL. Childhood obesity: are we all speaking the same language? Adv Nutr 2011; 2(2): 159S–66S. doi: 10.3945/an.111.000307

  69. Lobstein T, Baur L, Uauy R, IASO International Obesity Task Force. Obesity in children and young people: a crisis in public health. Obes Rev 2004; 5 Suppl 1: 4–104. doi: 10.1111/j.1467-789X.2004.00133.x

  70. Martin-Calvo N, Moreno-Galarraga L, Martinez-Gonzalez MA. Association between body mass index, waist-to-height ratio and adiposity in children: a systematic review and meta-analysis. Nutrients 2016; 8(8): 512. doi: 10.3390/nu8080512

  71. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Simple tests for the diagnosis of childhood obesity: a systematic review and meta-analysis. Obes Rev 2016; 17(12): 1301–15. doi: 10.1111/obr.12462

How to Cite
ArnesenE. K., ThorisdottirB., Lamberg-AllardtC., BärebringL., NwaruB., DierkesJ., RamelA., & ÅkessonA. (2022). Protein intake in children and growth and risk of overweight or obesity: A systematic review and meta-analysis. Food & Nutrition Research, 66.
Nordic Nutrition Recommendations 2022